Is Bipolar Disorder Overdiagnosed in Children and Adolescents: A Virtual Debate

Kiki Chang, MD; Gabrielle Carlson, MD; Stephen M. Strakowski, MD

Disclosures

September 10, 2010

In This Article

Conclusion: Addressing the Controversy

Dr. Strakowski: Not to impede this interesting discussion, but how do these considerations reflect back on the original "debate" of whether or not BD is over-diagnosed in kids? Is it simply that we have a group of kids who have behavioral problems, but who don't fit well anywhere diagnostically so that some docs push them into BD and some don't?

Dr. Chang: Yes, I believe that in many cases that is exactly what happens.

Dr. Carlson: I think we have considerable agreement, although the devil is in the details. "Cade's disease" is rare in kids. The further you stray from that, the more common "bipolar" becomes, but when people said it was rare, I think they meant "Cade's disease." Same thing is true for depression by the way. When child psychiatrists of old said that childhood depression didn't exist, it turns out they meant the kind of "involutional melancholia" that they were seeing in adults didn't exist -- not that miserable kids didn't exist. Our DSM criteria don't make the distinction. But then again, years of research never could isolate what was meant by melancholia or endogenous.

We are a ways away from a biomarker. There is no question that bipolar disorder is a spectrum. In kids, the additional wrinkle is a developmental one (ie, some mood regulation is immaturity and some is hard-wired). The term "kids" has quite a duration. I really think it extends through young adulthood, although there is no magical end. Perhaps it's when the last neuron in the prefrontal cortex that is going to myelinate does so.

Bipolar disorder has become what we made it but I'm not sure we made it correctly. The criteria tried to imitate the disease and didn't do so perfectly. So, like paint by numbers, we have an approximation, not a good forgery.

We need to be cleaner in our terms. I still like the way Judy Rapoport made a designation for childhood schizophrenia and gave her "prodromal guess" another name. We should have done that with bipolar disorder and separated Cade's disease from secondary mania (I mean secondary in the old sense that some other disorder occurred first) and BD NOS from mixed BD II and from people who become activated secondary to medication. I am increasingly of the opinion that "mixed" is more depressive than manic depressive by the way.

I agree that we need a standardized assessment, but the K-SADS, like DSM IV, is still like the bible and subject to interviewer interpretation in ways that we are ignorant about. I think it should be done at the end of the clinical interview not instead of it, but again, I think it would be an interesting study to see what, if any, difference that makes. At the risk of sounding narcissistic, I've always been about 15 years ahead of what comes to be accepted as wisdom. For instance, it is with some mirth I look at the fact that people are considering "irritability" in kids as related to depression in adults. I fought long and hard in the DSM IV committee to keep it in the criteria for children. People disagreed with me for a long time but seem to be coming around.

The kids we are being referred as child psychiatrists are much sicker than they used to be. That I can document since I save everything and can look at my evaluations from 1990 and now. I don't know if it is a gene and environment interaction or an epigenetic thing. I tend to think the latter.

We need a way of diagnosing the diagnostically homeless PDD-like kids.[14] They are mucking up the works in research because they meet criteria for certain things, but also have other stuff we don't ask about. We also need a way to accurately label them for clinicians seeing patients. We also need a way to diagnose them so we can follow them up and see what happens to them. That isn't even on the drawing board.

That brings me to TDD-D. Explosive, irritable kids are at the heart of the "bipolar controversy." Here is what I think we should do about it (Figure 1). Tell me what you think. If we are to better diagnose explosive and irritable children, one suggestion is to determine if the irritable rage outbursts occur episodically and accompanied by other manic symptoms. If they have been chronic, then the question is whether the child's mood is always irritable and his/her explosiveness is a result of that. The "temper dysregulation disorder with dysphoria" designation comes from the work of Dr. Ellen Leibenluft and her lab who has done research on "severe mood dysregulation." That disorder, however, requires a rule out of major depression and post traumatic stress disorder. My concern is twofold. First, I see many children with low frustration tolerance whose mood is fine until they don't get their way. They then go ballistic. The other concern is that children can be explosive and have many disorders, such as major depression, social phobia, autism, separation anxiety, ADHD, oppositional defiant disorder, conduct disorder, schizophrenia etc. Most children with those conditions don't become explosive but some do. So my thought is to have explosiveness as a modifier. The child would be diagnosed, say, with post-traumatic stress disorder with explosive outbursts, or ADHD with explosive outbursts. It would still be incumbent on the clinician to make the major diagnosis. Without that, I agree with Kiki. We are out of the frying-pan of calling all explosive kids bipolar, and missing other disorders, and into the fire of saying they have TDD-D. For those very rare children who have no other diagnosable disorder and become explosive, they would be given an "intermittent explosive disorder" diagnosis.

Figure 1. Possible solution to "the bipolar controversy."

Dr. Strakowski: It sounds like we've reached a point where we agree that our current criteria for behavioral disorders in kids (and also perhaps in adults) lack the nuance necessary to add validity and isolate "real" syndromes; consequently, the label "bipolar disorder" may be too loosely or prematurely assigned. Do we think that this problem is more common now than it used to be and, if so, is it a problem? Is there a better alternative? Does it occur everywhere?

Dr. Chang: Gaye -- I like your proposal a lot. Well most of it at least. The general idea seems to be, "Hey, if kids have chronic irritability and explosive outbursts, let's not just automatically call them bipolar, let's figure out what else they have and give them a qualifier (with explosive outbursts)." I am in consensus with that approach. I am not in consensus with the TDD-D thing. First of all, what is "temper dysregulation?" That kids get real angry? That's fine, there are some kids who have that, usually due to the irritability and other symptoms you can pin down closer to some other disorder -- and if not the full disorder, then at least NOS (PDD NOS, depressive disorder NOS, anxiety NOS, etc). I see little actual need for TDD. Let's just educate people not to use "bipolar disorder" willy-nilly!

Also, in Figure 1, wouldn't you need another fork coming from the episodic irritability category? That is, if it's episodic, it can't just be bipolar disorder. It could still be episodes of MDD or other diagnoses, correct?

Finally, if you have irritability between outbursts, you could still have a chronic dysthymia with some other episodes on top of it (major depressive disorder, BD, anxiety NOS, etc). So I'm afraid if people see that TDD or severe mood dysregulation are major possibilities in that category, they will use those instead of getting at other underlying causes. So I guess I am just a curmudgeon on this TDD-D thing -- I just don't see where it belongs! And trust me, I would love to be able to take all the explosive irritable kids in my clinic and give them a nicely wrapped diagnosis (TDD-D) and send them on their way, but I don't believe that is capturing them correctly or going to help matters any more.

In sum, it seems that we agree on many points. My strongest feelings are the need for longitudinal studies incorporating biologic markers and careful phenomenological assessment. And while I may be biased by my primary research studies, I feel it is of utmost importance to take a preventative angle, and study early presentations of BD (including all spectrum disorders) in this manner.

Dr. Strakowski: In the end, it appears that the boundaries of BD in young people remain undefined, but as we advance new technologies (eg, genetics, imaging), we might be able to identify subgroups that have specific course and treatment response patterns that then better define the remaining subjects. For now, careful, systematic, long-term evaluation under the care of a thoughtful psychiatrist remains these patients' best hope.

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